Provider Demographics
NPI:1336492891
Name:LEE, CHARLES J (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26893 BOUQUET CANYON RD # 152
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91350-3500
Mailing Address - Country:US
Mailing Address - Phone:310-845-6705
Mailing Address - Fax:
Practice Address - Street 1:14711 PRINCETON AVE STE 12
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-1469
Practice Address - Country:US
Practice Address - Phone:805-529-4821
Practice Address - Fax:915-744-5746
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28453122300000X, 1223G0001X
CA105729122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice